Provider Demographics
NPI:1881422848
Name:MIKUSA, KATHERINE (DTR)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:MIKUSA
Suffix:
Gender:F
Credentials:DTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 JONATHAN LN
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1336
Mailing Address - Country:US
Mailing Address - Phone:609-332-0382
Mailing Address - Fax:
Practice Address - Street 1:2301 E EVESHAM RD STE 111
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4504
Practice Address - Country:US
Practice Address - Phone:856-861-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered